We are currently accepting application forms for the 2017-2018 school year. Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us at: 516-767-8672.

Click here to print and mail in application form.

Please note that one registration form per family is needed.

STUDENT INFORMATION
CHILD 1
First Name   Last Name
Hebrew Name   D.O.B.
Age   Gender Boy Girl
School   Grade Entering
CHILD 2
First Name   Last Name
Hebrew Name   D.O.B.
Age   Gender Boy Girl
School   Grade Entering
       
Is the natural mother of the Child(ren) Jewish?    
Were there any conversions or adoptions in the Family? Yes No   If Yes - please explain
Previous Jewish Education Yes No   If yes - where?


PARENT INFORMATION
Father's Name   Hebrew Name
Home Phone   Father's Cell
Father's Email   Occupation:
Mother's Name   Hebrew Name
Home Phone   Mother's Cell
Mother's Email   Occupation
Address   City, State, Zip
Synagogue affiliated with:


MEDICAL INFORMATION
Persons to be contacted in case of an emergency when parents cannot be reached:
(Please provide at least two contacts)
Name   Relationship to child
Phone      
Name   Relationship to Child
Phone      
Family Physician   Phone

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.


As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of PW Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of PW Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad of PW Hebrew School activities and that these pictures may be used for marketing purposes.

I Accept

Name:
Initials:

PAYMENT OPTIONS Full tuition: $895.00 (Members $495.00)
Yes, we are members of Chabad of Port Washington
No, we are not members of Chabad of Port Washington
 Kindergarten Program, Free of Charge

Early Bird Special!
Yes, I'm registering before May 24, 2017 and would like to receive the 10% discount.

Please choose one of the following payment options:
1. One Full Tuition Payment
2. 10 Equal payments charged on the first of the month August - May

Payment Method:
Please Bill Me Please charge my card below


Credit Card Information:
Name on card   Card Type
Charge Amnt.   Card Number
Exp. Date   CVV Code 3 digits on back of card


We look forward to a wonderful year of learning and growth!